Wrong-Site Procedures: Preventable Never Events that Continue to Happen

Abstract

A comprehensive discussion of "never events" or preventable and grievously shocking medical errors that may result in serious morbidity and mortality is incomplete without a thorough analysis of wrong-site procedures (WSP). These occurrences are often due to multiple, simultaneous failures in team processes and communication. Despite being relatively rare, wrong-site surgery can be devastating to all parties involved, from patients and families to healthcare workers and hospitals. This chapter provides a general overview of the topic in the context of clinical vignettes discussing specific examples of WSP. The goal of this work is to educate the reader about risk factors and preventive strategies pertinent to WSP, with the hope of propagating the knowledge required to eliminate these "never events." To that end, the chapter discusses pitfalls in current surgical practice that may contribute to critical safety breakdowns and emphasizes the need for multiple overlapping measures designed to improve patient safety. Furthermore, updated definitions regarding WSP are included in order to better characterize the different types of WSP. Most importantly, this chapter presents evidence-based support for the current strategies to prevent wrong-site events. A summary of selected recent wrong-site occurrences is also provided as a reference for researchers in this important area of patient safety.

Defining Adverse Events and Determinants of Medical Errors in Healthcare

“…Effects of "Wrong-site procedures" are significant, starting with the psychological and physical harm to the patient. Moreover, the affected patient's loved ones are likewise highly likely to suffer emotional effects of having been, not in a direct manner, unprotected to a wrong-site event [5].…”

Frozen Section Timeout: Pilot Study to Reconcile Margins Using 3D Resected Specimen and Defect Scans

“…Despite the success of preoperative timeouts and the WHO Surgical Safety Checklist, communication failures between physicians persist as one of the most common threats to patient safety. [16][17][18] Some members of the surgical team may be reluctant to challenge the judgment of the surgeon due to medicine's hierarchical structure; 19,20 thus, oversights are more likely to remain unchecked. Despite these failures in communication and potential for medical errors, few studies focus on designing strategies to facilitate basic communication processes intraoperatively.…”

“…Despite the success of preoperative timeouts and the WHO Surgical Safety Checklist, communication failures between physicians persist as one of the most common threats to patient safety 16–18 . Some members of the surgical team may be reluctant to challenge the judgment of the surgeon due to medicine's hierarchical structure; 19,20 thus, oversights are more likely to remain unchecked.…”

Introductory Chapter: Patient Safety and Quality of Care - Inextricably Linked and Absolutely Essential Components of Modern Healthcare

“…From a focus on teams to simulation to electronic health records utilization, the content included herein stresses the Contemporary Topics in Patient Safety -Volume 1 importance of constructive and synergistic approaches toward ensuring the provision of quality and safety our patients deserve. Similarly, the various chapters in this volume explore the importance of concepts as diverse as multi-disciplinary approaches, camaraderie, and simulation, to help attain the most important singular and ultimate goal-a "zero defect" healthcare environment [13,15]. One key aspect, unique about the current book -and we would like to heavily stress this -is the increased emphasis on the critical importance of training on patient safety and care quality during the graduate medical education phase of professional development.…”

“…For example, while the implementation of the universal surgical checklist is globally accepted as the "gold standard" in operative patient safety [16], cases still occur where an entire operating room team "agrees" on an incorrect answer or team members fail to actively participate in the process. Such scenarios can easily become associated with retained surgical items or wrong-site surgeries [15,17]. Consequently, lack of an appropriate championship, combined with a lack of appropriate team focus, can still produce disastrous consequences despite the most well-designed safety systems being in place.…”